Percutaneous Transhepatic Cholangioscopy: Technical Evolution and Expanding Clinical Roles

Percutaneous transhepatic cholangioscopy (PTCS) has evolved from a niche diagnostic technique into an increasingly versatile platform for managing complex biliary diseases, particularly in patients with surgically altered anatomy or failed conventional endoscopic access. Early applications were limited by suboptimal visualization, rigid instrumentation, and procedural complexity. Refinements in endoscopic design and percutaneous techniques now support direct intraductal visualization and targeted intervention through a transhepatic tract. Recent developments include digital single-operator systems, scope miniaturization, and dedicated therapeutic accessories. These advances facilitate targeted biopsy and lithotripsy, although comparative evidence for improved diagnostic accuracy, safety, or patient-centered outcomes remains limited. Relevant literature was identified through a targeted PubMed/MEDLINE search through October 17, 2026, and reference-list screening, with bibliographic verification in Crossref. This narrative review distinguishes PTCS-specific evidence from peroral and mixed-access cholangioscopy studies and summarizes representative clinical outcomes. Technical success, diagnostic yield, malignancy-discrimination accuracy, and therapeutic success are considered separately. The review also addresses collaboration with interventional radiology, access selection, staged versus single-session procedures, drainage management, and alternative treatment pathways. Existing evidence remains heterogeneous in procedural indications, outcome definitions, adverse-event reporting, and device generations. Three-dimensional reconstruction has limited comparative clinical data, whereas the cited artificial intelligence application is a peroral feasibility report without established PTCS benefit. This synthesis aims to clarify the current role of PTCS in hepatobiliary practice and identify priorities for technique standardization, safety reporting, and prospective comparative validation.